Quan l'excepcionalitat promou la discrecionalitat a l'avaluació econòmica

 The Innovative Medicines Fund: a universal model for faster and fairer access to new promising medicines or a Trojan horse for low-value creep?

Ja fa anys que es va iniciar un mecanisme per capgirar l'avaluació de tecnologies al NICE. El 2010 es va constituir el Cancer Drug Fund amb 50m £ que al 2015 s'havia multiplicat gairebé per 7 i segueix així en 340m. Molts vam veure aquella operació com una forma de crear l'excepcionalitat dins l'avaluació econòmica, el cost-efectivitat podia quedar tocat i enfonsat a partir d'aquell moment. I si es començava pel càncer doncs ja no hi hauria argument per altres malalties. I si això passava al NICE, doncs també podia passar a altres països. 

Tal dit tal fet, en plena pandèmia, el 2021 es va crear el Innovative Medicines Fund pel mateix import que el de càncer 340m. Ara l'excepcionalitat total és de 680m  £. Els criteris d'assignació estan descrits sota del gràfic:

Un article recent ho comenta i al final diu:

In conclusion, the IMF, like the CDF, should be an exceptional route to patient access while providing the requisite evidence (mainly from RCTs) for reducing uncertainty about a drug’s clinical and cost effectiveness. Potential inclusion in the IMF should be limited to those cases where the major uncertainties can be addressed within the defined time frame. The notion of opportunity cost must not be ignored as IMF funding could always be used for other health services and technologies with strong evidence on effectiveness and value for money, which could improve overall population health.

Doncs bé, ja ho tenim. L'excepcionalitat creix i tinc la impressió que no té aturador, font de discrecionalitat o arbitrarietat?. Mals temps per a criteris objectius d'assignació social de recursos, mals temps per a l'avaluació econòmica. Recordeu sempre que la discrecionalitat és una font de poder polític i econòmic fantàstica (i font de corrupteles). Qui prova la discrecionalitat no la deixa, és addictiva.

PS. Tot això de moment no passa aquí aprop, els polítics consideren que no cal l'avaluació de tecnologies. 

PS. La meva opinió breu sobre avaluació econòmica a p.24 d'aquest document

The massive information leak ever known

No Place to Hide: Edward Snowden, the NSA, and the U.S. Surveillance State

 If someone says to you that a governmental agency has been collecting  data on more than 97 billion emails and 124 billion phone calls in just 30 days, you'd probably think that it is not possible. Imagine a system that has the capacity to reach up to 75% of US emails (!). This is impressive.
Unfortunately, this is absolutely true. Nobody has  rejected it at NSA.One year after the Snowden disclosure of surveillance activities, the US Congress has had to change existing laws and Courts  that allowed such practices.

The international data collected in a single thirty-day period from Germany (500 million), Brazil (2.3 billion), and India (13.5 billion). And yet other files showed collection of metadata in cooperation with the governments of France (70 million), Spain (60 million), Italy (47 million), the Netherlands (1.8 million), Norway (33 million), and Denmark (23 million).

As you may imagine this is not a US issue, but unfortunately the impact and public pressure for change over politicians is different across countries.

I've finished reading the Greenwald book and The Snowden files. I suggest you to start with Greenwald one, the original source better than the remake. I think that one of the most interesting parts is when he explains the rationale for his information disclosure, in Chapter 2:

“The true measurement of a person’s worth isn’t what they say they believe in, but what they do in defense of those beliefs,” he said. “If you’re not acting on your beliefs, then they probably aren’t real.”

  “I do not want to live in a world where we have no privacy and no freedom, where the unique value of the Internet is snuffed out,” Snowden told me. He felt compelled to do what he could to stop that from happening or, more accurately, to enable others to make the choice whether to act or not in defense of those values.

 The book is a milestone over the conflict between freedom and surveillance, over the value of privacy in our current times. It explains many details and raises a lot of uncertainty when using internet for any reason.

PS. By the way, I haven't seen any request to our politicians about how many emails have been suplied to US authorities, how they can justify such leakage and how they have selected them. Somebody must responsible for that.


PS. New report on integrated care, by Antares.

Parov Stelar, All night

Les decisions basades en la ignorància en temps de pandèmia

 Divided We Survive? Multilevel Governance during the COVID-19 Pandemic in Italy and Spain

L'avaluació de polítiques públiques és l'assignatura que menys agrada als governs. Els agrada tan poc que no hi dediquen recursos i si algú treu conclusions, aleshores fan com si no passés res.

Allò que va passar durant la pandèmia sabem tots que va ser molt fort. Em refereixo a decisions que es podien haver pres, que sabíem quines podien ser i en quin moment calia prendre-les. Em refereixo a decisions sobre les que no hi havia competència per prendre-les. Totes aquestes decisions incertes van tenir conseqüències, algunes d'elles letals i que no seran quantificades ni ningú se'n farà responsable. A data d'avui el nostre cervell és molt ràpid en oblidar tot plegat.

Podeu consultar en un article recent quin va ser el resultat comparat de prendre decisions mitjançant coordinació descentralitzada o centralització jeràrquica. És a dir, aprofitant petites peces d'informació local en un context d'ignorància o no. El resultat va ser aquest:

We document that in Spain, the pre-crisis governance mechanisms that would prove crucial in a pandemic were effectively paralyzed with the implementation of a single command that effectively centralized healthcare decision-making, and to large extent, inhibited incentives for cooperation between different governments. That is, the logic of the state of alarm deterred information sharing and regional co-governance. 

In contrast, in Italy, intergovernmental tensions emerged only in the second wave, when it was clearer how to manage the virus. During the first wave of the pandemic, regions passively allowed an increasing coordination role led by the central state. However, given that such coordination was not hierarchically imposed, it did not reduce the incentives to share information on best practices, or to implement more restrictive policies at the regional level. Comparing the reactions to the pandemic in two countries (Italy and Spain) allows us to study whether hierarchical centralization in Spain fared  better than informal decentralized coordination implemented in Italy. Our findings suggest that decentralized governance gives rise to better health outcomes and outputs than hierarchical  centralization.

I la conclusió:

When the source of the pandemic is localized and policy uncertainty is high (as during the first wave of the pandemic), a decentralized coordination mechanism, even when passively adopted, such as in Italy, would be advantageous (better outcomes and outputs) because it combines enhanced coordination, particularly information sharing and the profiling of their policy restrictions to the regional needs and priorities, above and beyond those of the central government.

Estic convençut que si tornés una altra pandèmia tornarien a replicar-se els mateixos errors. I és que l'error bàsic és trobar-nos enmig d'aquest enigma de dominació jeràrquica del que no hi ha manera de sortir-ne.

PD. I de l'excés de mortalitat actual i d'aquest estiu passat, gairebé no se'n parla.

Reflexió en veu alta

Daring to Practice Low-Cost Medicine in a High-Tech Era

El NEJM ens ofereix una elemental i oportuna reflexió d'un metge sobre tal com veu la pràctica de la medicina als USA. Però pel que diu també podria ser en un lloc molt proper.
Diu:

Most doctors are intensely risk-averse. We don't tolerate uncertainty. Not wanting anything bad to happen, we reflexively overtest and overtreat in order to protect our patients — and ourselves. We feel judged by everyone — ourselves, our colleagues, our patients, the health care system, and the lawyers. The meaning of “first do no harm” has changed for us. We feel that “doing everything” is the best practice and the way to prevent harm, and we believe that it will shelter us from blame. We order tests and treatments because they are available to us, well before their importance has been established, their safety has been determined, and their cost–benefit ratio has been calculated.

I aleshores mostra la necessitat de redescobrir el valor del criteri clínic. I acaba en coses que sabem. La importància del canvi del comportament i presa de decisions individual i col.lectiva, en els metges i la comunitat mèdica i científica.
Al final un diria que si no l'hagués publicat el NEJM té un punt naïf, dejà-vu. O és que el NEJM ha canviat d'orientació?, no ho crec pas. És tant sols una reflexió que un metge vol compartir amb els lectors, els de NEJM l'han acceptada i s'agraeix.

The largest global public-health initiative

 The COVID-19 vaccines are here: What comes next?

From McKinsey:

As vaccine availability nears, communities and consumers will want answers to many questions, including:

• Is the vaccine effective and safe?
• Who will get vaccinated first?
• Which vaccine will we receive, especially if multiple vaccines are available?
• Where and when can we get vaccinated?
• Will we have to pay?
• Above all, what do we need to worry about?

Although the scale of the task may seem daunting, countries benefit by starting end-to-end planning immediately. Our 6A framework lays out a structured approach to ensure vaccines are available, administrable, accessible, acceptable, affordable, and accountable while taking into account strategic considerations associated with uncertainty (for example, vaccine clinical and technical profile) and building system capabilities (Exhibit 2). We have developed, in granular detail, the individual activities and considerations behind each component of the framework. Through the collective initial effort of the pharma industry, the scientific community, global health institutions, and governments, most elements of the “available” segment of the 6A journey are being addressed

 

Paul Strand

 

The value of vaccination

Valuing vaccination

A PNAS article sets a broader perspective on valuing vaccines. It is of interest in light of current difteria case. My position is clear, no doubt about mandatory vaccination if its cost-effectiveness is proven.
Suggestions from the article:

Three general recommendations flow from our arguments and related synthesis of existing evidence on broad benefits of vaccination. First, many economic evaluation studies of vaccinations should be redone to capture the full benefits generated by the vaccination in question. Second, the evidence to date on the full value of vaccination has been focused on measuring the total social benefits generated. It would also be useful to explore the distribution of vaccination’s benefits among different possible beneficiaries. Third, the primary empirical evidence on broad vaccination benefits will need to be considerably expanded and improved

Framework of vaccination benefits

Perspective		Benefit categories	Definition
Broad	Narrow	Health care cost savings	Savings of medical expenditures because vaccination prevents illness episodes
		Care-related productivity gains	Savings of patient’s and caretaker’s productive time because vaccination avoids the need for care and convalescence
		Outcome-related productivity gains	Increased productivity because vaccination improves physical or mental health
		Behavior-related productivity gains	Vaccination improves health and survival, and may thereby change individual behavior, for example by lowering fertility or increasing investment in education
		Community health externalities	Improved outcomes in unvaccinated community members, e.g., through herd effects or reduction in the rate at which resistance to antibiotics develops
		Community economic externalities	Higher vaccination rates can affect macroeconomic performance and social and political stability
		Risk reduction gains	Gains in welfare because uncertainty in future outcomes is reduced
		Health gains	Utilitarian value of reductions in morbidity and mortality above and beyond their instrumental value for productivity and earnings

 

Book choice

Patient Care under Uncertainty

How testing market fails during a pandemic

What Caused the COVID-19 Testing Deficit?

The evidence of market failure during this pandemic is everywhere. Shortages, excessive prices, unavailable capacity...It is a clear example of mismatch between demand and supply. The question is, Can we do it otherwise?. In this article there are some hints for resource allocation for testing activities.

Globally, the development of diagnostics has long been left to markets, many of which are highly specialized. But while there are diagnostics markets for major infectious and non-infectious diseases, and even neglected tropical diseases, there is none for pandemic diseases.
Governments can of course counteract market deficiencies, but the commonly used mechanisms still require a trace level of demand, which does not exist for pandemic-disease diagnostics until the brink of an outbreak. And national governments, subject as they are to political and ideological constraints, cannot be relied upon always to create markets with the same swiftness demonstrated by South Korea. Reactive market creation is therefore not the way forward.
Instead, national governments should support the creation of a global coordinating platform for pandemic preparedness. Such a platform can take the lead in raising and pooling capital to channel toward rapid development, production, and distribution of diagnostics for pandemic diseases.
The blueprint for such a platform already exists. The Coalition for Epidemic Preparedness Innovations (CEPI) is a coordinating mechanism focused on advancing vaccine development and facilitating clinical validation, mass-scale manufacturing, and stockpiling. By reducing uncertainty and minimizing disruptions, CEPI makes vaccine markets more secure, accessible, and dynamic.
CEPI relies on both traditional financing (large grants from governments and foundations) and innovative financing (the returns from instruments like the International Finance Facility for Immunization, or IFFIm). In the event of an outbreak, CEPI uses instruments like Advanced Market Commitments (AMCs) or volume guarantees – which can be structured through mechanisms like the Global Health Investment Fund and InnovFin, or as conditional pledges to IFFIm and Gavi, the Vaccine Alliance – to enable it to scale up production quickly.
This blueprint can easily be replicated for diagnostics. All that is needed is a specialized entity – an institution or initiative that couples research and development with market access. 

Investing in pandemic preparedness

 The Cost Effectiveness of Stockpiling Drugs, Vaccines and Other Health Resources for Pandemic Preparedness

A short review on the topic, many questions, few answers. 

Health economics methods can be used to decide the optimal pandemic preparedness strategy based on cost effectiveness because different stockpiling of available measures can be implemented. The economic evaluation of pandemic preparedness strategies and pandemic preparedness measures is based on methods developed for health technology assessment. Nevertheless, this assessment differs from the traditional economic evaluations. The cost-effectiveness evaluation of a new drug compares healthcare costs and health effects for patients treated and not treated with the drug. The cost effectiveness of the drug will depend on the effectiveness of the drug in reducing clinical outcomes and healthcare costs. The drug will be used by the health system in patients with certainty. In contrast to this, the cost-effectiveness evaluation of pandemic preparedness measures and interventions is affected by several facts. First, pandemic preparedness measures are costly because they must be used to prevent and treat pandemic infections in a great number of persons. Second, investments in pandemic preparedness measures could be made many years before the emergence of the pandemic pathogen. Third, the health and economic benefits generated by pandemic preparedness measures will depend on the virulence and infectiousness of the pandemic pathogen. Fourth, pandemic preparedness measures can be associated with large costs and benefits outside the health system and great macroeconomics effects. There is a risk that an unknown pandemic agent will emerge and cause high morbidity and mortality, but we do not know when this will happen or how virulent and infectious a new pandemic agent will be. Although a new pandemic can be similar to previous pandemics, it can be also very different.

Ventilator support and intensive care for acute respiratory failure due to acute respiratory distress syndrome is a cost-effective intervention [8], but the cost effectiveness of stockpiling ventilators depends on the number of stockpiled ventilators and the severity of a future pandemic. The cost effectiveness of ventilator support and intensive care ranges from US$29,000 per QALY in low-risk patients (≥ 70% probability of surviving at least 2 months from the time of ventilator support) to US$110,000 per QALY in high-risk patients (prognostic estimate ≤ 50%) [7]. The question about the optimal number of stockpiling ventilators for pandemic preparedness depends on intervention costs and uncertainty about when the pandemic will happen and how virulent and infectious the pandemic pathogen will be.

Paul Strand at KBr

 

Distributional cost-effectiveness

 Distributional Cost-Effectiveness Analysis. Quantifying Health Equity Impacts and Trade-Offs

Distributional Cost-Effectiveness Analysis Comes of Age

Distributional cost-effectiveness analysis (DCEA) provides information about the equity impacts of health technologies and programs and the trade-offs that sometimes arise between equity and efficiency. This field has now come of age with a growing applied literature,1 new training resources,2 and a formal professional network: a special interest group on equity-informative economic evaluation within the International Health Economics Association

The outline of the book:

Part One: Preliminaries

1:Introduction, Richard Cookson, Susan Griffin, Ole F. Norheim, Anthony J. Culyer

2:Principles of health equity, Richard Cookson, Anthony Culyer, Ole F. Norheim

3:Designing a distributional cost-effectiveness analysis, Richard Cookson, Susan Griffin, Ole F. Norheim, Anthony J. Culyer

4:Describing equity impacts and trade-offs, Richard Cookson, Susan Griffin, Ole F. Norheim, Anthony J. Culyer

5:Introduction to the training exercises, Richard Cookson, James Love-Koh, Colin Angus, James Lomas

Part Two: Simulating Distributions

6:Health by disease categories, Kjell Arne Johansson, Matthew M. Coates, Jan-Magnus Økland, Aki Tsuchiya, Gene Bukhman, Ole F. Norheim, Øystein Haaland

7:Health by social variables, James Love-Koh and Andrew Mirelman

8:Costs and health effects, Colin Angus

9:Health opportunity costs, James Love-Koh

10:Financial protection, Andrew Mirelman and Richard Cookson

Part Three: Evaluating Distributions

11:Dominance analysis, Owen O'Donnell and Tom Van Ourti

12:Rank-dependent equity weights, Owen O'Donnell and Tom Van Ourti

13:Level-dependent equity weights, Ole F. Norheim, Miqdad Asaria, Kjell Arne Johansson, Trygve Ottersen and Aki Tsuchiya

14:Direct equity weights, Mike Paulden, James O'Mahony and Jeff Round

Part Four: Next Steps

15:Uncertainty about facts and heterogeneity of values, Susan Griffin

16:Future challenges, Richard Cookson, Alec Morton, Erik Schokkaert, Gabriela B. Gomez, Maria Merritt, Ole F. Norheim, Susan Griffin, and Anthony J. Culyer

The right rate

International Variations in a Selected Number of Surgical Procedures

If you want to be astonished by the huge variation on the rate of surgical procedures in OECD countries, have a look at this report. It is difficult to find arguments for such a huge differences in health care. The key statement:

The data presented here provide contemporary assessments of the size of the clinical margins of uncertainty for the procedures studied. These may also in part be a consequence of varying legal constraints, methods of payment, availability of cover and patient preferences. They therefore provide basic evidence for research priorities in an increasingly evidence-based medicine paradigm. The only way to make proper judgements on the optimal level for a particular procedure is to have national longitudinal data linking individuals’ treatment (and deliberate withholding of treatment) to outcomes. Such data do not exist in most countries. This is a critical deficiency in health service delivery, which means current policy on which procedures to fund, for whom, is formulated in circumstances based more upon local custom and scientific tradition than empirical effectiveness data.

Meanwhile you can add this report to the folders with the Atlas VPM that you may already know.

Where is the regulator?

Understanding the Economic Value of Molecular Diagnostic Tests: Case Studies and Lessons Learned

Maybe we have just arrived at the expected moment, when the cost of one whole genome sequencing is below $1000. (mapping up to 25.000 genes). At the same time, one test for 21 genes may cost you $4.500. This is our crazy world. In the first case you will only know your genome, in the second there will be a probability of success from a certain therapy.
There's only one question: Does anybody know any information about the reliability of such probabilities beyond the firm that is selling the test?. Where is the regulator?
After reading a recent article on the value of molecular diagnostic tests, I'm convinced that we still remain in an uncertain world in need of transparency. Given such uncertainty, better keep calm until the regulator confirms the clinical utility and cost-effectiveness of molecular diagnostic tests.

Parov Stelar Band - Jimmy's Gang (Unplugged in Moscow)

PS. You may avoid watching "The wolf of Wall Street" if you read this article.

Pandemic economic reasoning

 ECONOMICS IN ONE VIRUS. AN INTRODUCTION TO ECONOMIC REASONING THROUGH COVID-19

The outline of the book:

1. WHAT DOES IT MEAN TO BE ECONOMICALLY “WORSE OFF” DURING A PANDEMIC?

An introduction to economic welfare

2. SHOULD I BE FREE TO RISK INFECTING YOUR GRANDMA WITH A DEADLY VIRUS?

An introduction to externalities

3. DID WE CLOSE DOWN THE ECONOMY?

An introduction to public and private action

4. HOW MUCH WOULD YOU SPEND TO SAVE MY LIFE?

An introduction to the value of a statistical life

5. WHEN IS A LOCKDOWN CURE WORSE THAN THE DISEASE?

An introduction to cost-benefit analysis

6. WHY WAS I BANNED FROM GOING FISHING?

An introduction to thinking on the margin

7. WHAT GOOD IS A PANDEMIC PLAN WITH SO MANY UNKNOWNS?

An introduction to uncertainty and the knowledge problem

8. WHY DID PROTESTS AND MARCHES NOT LEAD TO OBVIOUS SPIKES IN COVID-19 CASES?

An introduction to endogeneity

9. WHY COULDN’T I GET A COVID-19 TEST BACK IN FEBRUARY AND MARCH 2020?

An introduction to regulatory tradeoffs

10. WHY WAS THERE NO HAND SANITIZER IN MY PHARMACY FOR MONTHS?

An introduction to the price mechanism

11. DOES THE PANDEMIC SHOW THAT WE NEED MORE U.S.-BASED MANUFACTURING?

An introduction to trade and specialization

12. WHY IS THAT GUY IN THE MASK GETTING SO CLOSE?

An introduction to moral hazard

13. WHY DID AIRLINES GET A SPECIAL BAILOUT BUT NOT MY INDUSTRY?

An introduction to public choice economics

14. WHY DIDN’T MY WORKERS WANT TO BE REHIRED?

An introduction to incentives

15. WHY WEREN’T WE WELL PREPARED FOR THE PANDEMIC?

An introduction to political incentives

16. CAN WE REALLY JUST TURN AN ECONOMY OFF AND BACK ON AGAIN?

An introduction to the nature of an economy

CONCLUSION: WHAT IS ECONOMICS GOOD FOR?

And a message on cost-benefit:

Cost-benefit analysis is a useful economic technique for considering whether a project improves societal welfare and to compare the societal net benefits of different projects. To do cost-benefit analysis well, we must account for all the direct and indirect impacts of the proposed policy on societal welfare, account for externalities, and ensure that we compare like-with-like in both timeframe and measurement. When it comes to COVID-19, cost-benefit analysis can, in theory, be used to examine the efficacy of lockdowns. However, there are huge uncertainties that make it hard to weigh up the precise costs and benefits of those policies. Even if the societal benefits do appear to exceed the costs on reasonable assumptions, that doesn’t mean the exact contours of the lockdown are “optimal policy.” In an ideal world, we’d find the policy mix that minimizes the overall societal costs of the pandemic.

This ideal world doesn't exist. 

QALYs and COVID

Revisiting the Economic Cost of Flattening the Curve

The Incidental economist blog provides information regarding QALY in the current pandemic. Forget the cost per QALY (so difficult to estimate in my opinion) and take only the 6,4 QALYs per death avoided.

It updates previous estimates and says:

The table below summarizes the previous calculations and current updates. Our revisited analysis shows that, as the shutdown continues, the cost per QALY gained increases exponentially due to the exponential growth in the total cost of both forgone productivity and business failure.

We previously emphasized that a key challenge in making calculations of this type is the uncertainty around the data inputs. Six weeks later, this still holds true, particularly for the range of QALY losses without a shutdown, i.e. the predicted corona-related deaths in the absence of intervention.

One interesting aspect of this analysis is that as time goes on, the cost per QALY gained will become higher and higher. This is because the net gains will diminish — the lives saved remains constant, but the offsetting life years lost due to other factors increase — while the costs increase exponentially. The key number that remains unknown is the relationship between the length of the lockdown and the number of lives lost.
In our first post, we concluded that the shutdown would meet conventional standards of cost effectiveness only if the deaths avoided was on the high end of the possible range and the costs on the low end — an outcome that seemed unlikely. Revisiting the issue, it is now clear that the cost per QALY gained from the shutdown will be outside the conventional range of acceptability even at the high end of deaths avoided. How far outside the range the shutdown policy will ultimately prove to be is unknown.

Confidential drug pricing without confidential prices

Performance-based managed entry agreements for new medicines in OECD countries and EU member states: How they work and possible improvements going forward

In this blog I've explained my position against confidential prices for drugs. However, there is an option to complicate it: confidential entry agreements. This is the current trend for high cost drugs with uncertain outcome. The report of the OECD explains the current situation in different countries and helps to shed light in this important issue. Just take this short statement and you'll be convinced of the complete mess:

It is difficult to assess to what extent performance-based MEAs have so far been successful. Few countries have formally evaluated their experience. Confidentiality of agreements continues to be a barrier to independent evaluation and little evidence is public. However, information available from expert interviews and from prior studies indicates that CED agreements have so far had a poor track record of reducing uncertainty around the performance of medicines. As a result, some countries have recently reformed CED schemes and some are discontinuing CED agreements altogether in favour of alternatives. The latter include restricted or conditional coverage without a MEA, whereby coverage is initially restricted to certain indications or patient groups and only broadened if and when additional evidence becomes available. Payment-by-result agreements continue to be used quite widely, but they do not always generate evidence
on product performance because data used for triggering payments are not always  aggregated and analysed.

Sophia Al-Maria at Tate

Dying from COVID

 Magnitude, demographics and dynamics of the effect of the first wave of the COVID-19 pandemic on all-cause mortality in 21 industrialized countries

The total mortality effect of the COVID-19 pandemic is the difference between the observed number of deaths from all causes and the number of deaths had the pandemic not occurred, which is not directly measurable. The most common approach to calculating the number of deaths had the pandemic not occurred has been to use the average number of deaths over previous years—for example, the most recent 5 years—for the corresponding week or month when the comparison is made. This approach, however, does not take into account changes in population size and age structure, nor long- and short-term trends in mortality, which are particularly pronounced for some age groups52,53. Nor does this approach account for time-varying factors, such as temperature, that are largely external to the pandemic but also affect death rates.

We developed an ensemble of 16 Bayesian mortality projection models that each make an estimate of weekly death rates that would have been expected if the COVID-19 pandemic had not occurred. We used multiple models because there is inherent uncertainty in the choice of model that best predicts death rates in the absence of pandemic. 

I suggest you to find where is Spain... 

Comparison of percent increase in deaths from any cause as a result of the COVID-19 pandemic between men and women, for all ages and by age group.

 

Drug pricing 101

In his book "Reinventing the bazaar. A natural history of markets", John McMillan says:

Market design consists of the mechanisms that organize buying and selling; channels for the flow of information; state-set laws and regulations that define property rights and sustain contracting; and the market’s culture, its self-regulating norms, codes, and conventions governing behavior. While the design does not control what happens in the market—as already noted, free decision-making is key— it shapes and supports the process of transacting.

If we look at the pharmaceutical market, there are unique features. The government role is at the same time the "market designer" and mostly the monopsonist. The price setting mechanism relies on multiple regulations that evolve according to circumstances. For example, since 2012 there has been no information about patented drug prices accepted for public funding. It sounds quite weird in a moment that everybody is proud of boosting transparency. The debates over the new pricing decree are still more strange. The current mess was explained some months ago in this op-ed. The uncertainty now also embraces pharma-distribution, pharmacists complain about the system.
Such a pricing system is explained in  this presentation (details about pricing in p.6). As far as it is unsatisfactory for everybody, it needs to be rebuilt. My suggestion is that there is a need to start from scratch. John McMillan would say that we have to look for a clever market designer to reinvent drug pricing as soon as possible.

Investing heavily (2)

Global Healthcare Private Equity Report 2014

One of the adverse effects of financial repression is that investors may lose their compass in the allocation of risk and the prediction of rewards. This repression period for savers will last longer than anybody would expect, since the size of public debt in some countries is still increasing. Therefore, now it is the time for private equity to invest in sectors with greater uncertainty over profits that would be desirable in normal conditions. This is one reason, among others, why hospitals may appear of interest and this is precisely what happened yesterday.
We know from a recent report that while overall private equity investment increased, capital deployed in healthcare declined in 2013.

Investment levels in the medtech and provider sectors in Europe were down in 2013 compared with 2012, when these sectors saw three $1 billion-plus deals between them. Deal value in the provider sector was especially slow, coming in at only a third of the level seen in 2012, partially due to the dearth of large deals like the previous year’s Mediq (a pharmacy distributor) and Four Seasons (nursing homes) deals.

In 2014 the trend could be the opposite, at least near here. The closed operation (1$ billion-plus) will change the landscape of private health care for decades, and some shocks may appear sooner than later. Let's wait for the strategic responses.

PS. It may seem a paradox, but the unintended effect of financial repression by governments is a misperception of risk. Speculative bubbles before the recession have had the same effect. Beware of that.

PS. Regarding yesterday's case, I understand that antitrust issues will be taken into account properly...

Les diferències en salut minven

 Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019

El missatge en positiu per a tots els que ens preocupen les diferències en salut és que hi ha evidència de la seva reducció en les darreres tres dècades. En un article al Lancet ho mesuren amb el Healthcare Access and Quality Index i diu:

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9–21·3), as well as among the young (22·5, 19·9–24·7), working (17·2, 15·2–19·1), and post-working (15·1,13·2–17·0) age groups.

Evidentment hi ha moltes diferències entre països desenvolupats i els que no ho són, el que ells mesuren amb un indicador sociodemogràfic SDI. I també hi ha diferències entre grups d'edat.

Això els porta a concloure que cal millorar:

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

Espanya es troba a 89,7 de l'índex, mentre que la mitjana d'Europa Occidental és a 87,2. Bé, em caldria més detall com ho fan amb altres àrees geogràfiques però no hi som.

L'esforç de l'Institut de Health Metrics and Evaluation és notable i el rigor és altíssim. Convé seguir-ho d'aprop amb dades més recents, després de la pandèmia.

Stanton

 

Retrofuturistic payment systems (2)

Long time ago I alerted about a potential payment system that tried to convince everybody and didn't satisfied its goals for equity and efficiency. I was concerned about reproducing the mistakes of the past and creating flaws for the future. What I said more than two years ago, has been recently confirmed more or less by a recent decree. Its detailed analysis goes beyond any post in a blog. The retro part is related to an administrative discretionary classification of hospitals that was initially defined two decades ago (Decree  June 30th, 1992) and failed afterwards. The future part is related to a dual payment system: population and service based that will be defined according to idiosyncratic situations. Both are the pillars of uncertainty in the model.
Right now the most important task to accomplish will be to think about its next reform.